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' M � MON ORING SYSTEM CERTIF, TIOA NEDD (or Use Gi•.Il Juriscliriions 11•ilhin theScale of'('uli%o>.i7il,l "" �� :1rNharih%(.'filed: Chapler G.7, fleullh anc/.S'clJ s Code; Chupler 16,-Division 3, /'idd?3, Z'cI/ o/hie/Code uf7�'c ulaliun.5 This form must be used to document testing and servicing of monitoring equipment. A separate certitfcE8il orlre QQ$ulst be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be rovided to the tank system owner/operator. The owner/operator must submit a copy of this form to the Ig�al within 30 days of test date. PERMIT/SERVICES A. General Information Facility Name: ej Bldg.No.: Site Address: 14-1fQq/T Ey Ci ee.tLToN Zi City: St p: 9tZotP Facility Contact Person: Contact Phone No.: (Z0" ) 3'544- ltg"S Make/Model of Monitoring System: "awe 7f.5- 3 60 Date of Testing/Servicing: B. Inventory of Equipment Tested/Certified Check the a i ro wiate boxetio indic:ile specific equipment ins ectewserviced: Tank ID: Tank ID: A In-Tank Gauging Probe. Model: P4 Xh5j/ ❑ In-Tank Gauging,Probe. Model: A Ar�aular Space or Vault Sensor. Model: ZO ❑ Annular Space or Vault Sensor. Model: ;4 Ppiiig Sump/Trench Sensor(s). Model: ZOO ElPiping Sump/Trench Sensor(s). Model: A Fill Sump Sensor(s). Model: Zy$ ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leal:Detector. Model: ❑ Mechanical Line Leak Detector. Model: fed Electronic Line Leak.Detector. Model: LJ > ❑ Electronic Line Leak Detector. Model: �. ❑ Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(s ecify equi orient type and model in Section E on Page 2). ❑ Other(specify equipment t e and model ipSection E on Pa a 2). +. Tank ID: Tank ID: ' Y• J� In-Tank Gauging Probe. Model: 4 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: IAC& ❑ Piping Sump/Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 2PP, ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: X Electronic Line Leak Detector. Model: PL-,L-0 ❑ Electronic Line Leak Detector. Model.- El Tank Overfill/High-Level Sensor. Model: ❑ Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment type and model in Section E on Page 2). ❑ Other(speci2 equipment ty e and model in Siction E on Pa e Dispenser 1D:— /f L Dispenser ID; -148 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: o$ ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: 9' -f O ❑ Dispenser Containment Sensor(s). Model: V DA ❑ Dispenser Containment Sensor(s). Model: g ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). 7DeID: Dispenser ID: er Containment Sensor(s). Model: %o$ ❑ Dispenser Containment Sensor(s). Model- alve(s). ❑ Shear Valve(s). 11 r Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. 111CILlde information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verity that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equi meat capable of generating such reports,I have also attached a copy of the report;(Check all that applt): &Sy yrs -u XAlarm history report Technician Name(print):. 74416 1 ,.,,,45 Signature: — Certification No.: License.No.: (![3 W �QG 33a7 +0 r Testing Company Name:—A&c A _ I r r Phone No.:0209 p/r Z, Site Address: 3g5tt Date of Testing/Servicing: 2//2 /619 _� Page I of 3 03101 Monitoring System Certification A Results of Testing/Servicing